Healthcare Provider Details

I. General information

NPI: 1740998939
Provider Name (Legal Business Name): SIERRA WHITE-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 100TH ST SW STE 100
LAKEWOOD WA
98499-2708
US

IV. Provider business mailing address

1200 INTREPID AVE
PHILADELPHIA PA
19112-1229
US

V. Phone/Fax

Practice location:
  • Phone: 253-588-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number61343809
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: